GW1--04349_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information: ,
Justin Radford 4.WATER ZONES�x • -
FROM TO L DESCRIPTION
Well Contractor Name ft. ft.
3270-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased-wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in. •
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)".
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 2 ft 2 in. Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft • ft. • in
3.Well Use(check well use): '17.SCREEN "°:� �_
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑Municipal/Public 2 ft 12 ft 2 1D' 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Conunercial ❑Residential Water Supply(shared) 18:_GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 0.5 ft grout pour
Non-Water Supply Well:
©Monitoring ❑Recovery 0.5 ft 1 ft bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1 ft 12 ft #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.5 ft Asphalt
4.Date Well(s)Completed: 04/1 7/23weu ID#MW-20 0.5 ft 12 ft• t I Ffl rl ty r wain
ft fth m.4. r!s .h �5 X�, ✓
5a.Well Location: ft. ft. J 4 J I 0 7 202.3
JP Davenport n/a ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. lnivfni;::w:Ni•7}''` .""" r
°"''3•., :
5961 Highway 264, Greenville,NC cal-:ii'�'71G
_ ft. ft.
Physical Address,City,and Zip 21.REMARKS "
Pitt 80232
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimtil degrees: 22.Certific on
(if well field,one tat/long is sufficient) ��'1
35.624490 N 77.225604 W 04/17/23
Signatur f Certified Well Contra Date
6.Is(are)the well(s): l]Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: unknown (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
n
11.Borehole diameter: 3• 5 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Direct Push 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013